[Pleural cavity concerns]. / Los quebraderos de cabeza del espacio pleural.

INTRODUCTION: Persistent air leak (PAL) is a common problem. We asses our experience in the management of these patients. MATERIAL AND METHODS: Retrospective review of patients with chest tubes after bronchopulmonary pneumothorax (due to lung resections, spontaneous pneumothorax, necrotizing pneumonia) from 2010 to 2015. We studied clinical data, PAL incidence, risk factors and treatment, considering PAL ≥ 5 days. RESULTS: Thirty-seven cases (28 patients) between 0-16years: 26 lung resections, 11 pneumothorax. We found no differences in the distribution of age, weight, indication or comorbidity, but we noticed a trend to shorter hospital stay in infants. Patients with staple-line reinforcement presented lower PAL incidence than patients with no mechanical suture (43% vs 37%), the difference is even apparent when applying tissue sealants (29% vs 50%) (p > 0.05). We encountered no relationship between the size of the tube (10-24 Fr) or the type of resection, with bigger air leaks the higher suction pressure. We performed 13 pleurodesis in 7 patients (2 lobectomies, 3 segmentectomies and 2 bronchopleural fistulas), with 70% effectiveness. We conducted 7 procedures with autologous blood (1.6 ml/kg), 2 with povidone-iodine (0.5 ml/kg), 2 mechanical thoracoscopic and 2 open ones. We repeated pleurodesis four times, 3 of them after autologous blood infusion: 2 infusions with the same dose (both effective) and the other 2 as thoracotomy in patients with bronchopleural fistulas. After instillation of blood 3 patients presented with fever. After povidone-iodine instillation, the patient suffered from fever and rash. CONCLUSIONS: Intraoperative technical aspects are essential to reduce the risk of PAL. Autologous blood pleurodesis, single or repeated, is a minimal invasive option, very safe and effective to treat the parenchymatous PAL.

INTRODUCCION: La fuga aérea persistente (FAP) es un problema común. Evaluamos nuestra experiencia en el manejo de estos pacientes. MATERIAL Y METODOS: Revisión retrospectiva 2010-2015 de pacientes con drenaje endotorácico por neumotórax broncopulmonar (resecciones pulmonares, neumotórax, neumonía necrotizante). Revisamos datos clínicos, incidencia de FAP, factores determinantes y tratamiento, considerando FAP ≥ 5 días. RESULTADOS: Treinta y siete casos (28 pacientes) con edades entre 0-16 años: 26 resecciones pulmonares, 11 neumotórax. No encontramos diferencias en distribución de edad, peso, indicación quirúrgica ni comorbilidad, aunque sí tendencia a menor estancia hospitalaria en lactantes. Los pacientes con sutura no mecánica presentaron más fugas que los pacientes con sutura mecánica (43 vs 37%), así como los pacientes a los que no se aplicaron sellantes tisulares (29 vs 50%) (ambos p > 0,05). No encontramos relación con el tamaño del tubo (10-24 Fr) ni con el tipo de resección, manteniendo más fuga aérea los de mayor presión de aspiración. Realizamos 13 pleurodesis en 7 pacientes (2 lobectomías, 3 segmentectomías y 2 fístulas broncopleurales), con efectividad del 70%. Realizamos 7 con sangre autóloga (1,6 ml/kg), 2 con povidona iodada (0,5 ml/kg), 2 mecánicas toracoscópicas y 2 abiertas. Se repitió la pleurodesis en 4 ocasiones, 3 de ellas tras sangre autóloga: dos con repetición de la misma dosis (ambas efectivas) y otras dos por toracotomía en los pacientes con fístula broncopleural. Tras la instilación de sangre 3 casos presentaron fiebre. Tras la de povidona iodada, fiebre y exantema. CONCLUSIONES: Los aspectos técnicos intraoperatorios son esenciales para disminuir el riesgo de FAP. La pleurodesis con sangre autóloga, única o repetida, es una opción poco invasiva, muy segura y efectiva para las FAP parenquimatosas en nuestra muestra.

[Fast track protocol for children undergoing appendicectomy]. / Protocolo de alta precoz tras apendicectomía en niños.

BACKGROUND: Multiple approaches to the treatment of simple and complicated (gangrenous or perforated) appendicitis in children have been promoted. Our goal is to develop a new protocol for these patients that allows shorter hospital stays without increasing complications rates. METHODS: Prospective collected data of patients undergoing appendicitis treated according to the new protocol for a period of 7 months were reviewed. This protocol consists on antibiotic prophylaxis in all cases continued with triple antibiotic regimen in complicated appendicitis. Antibiotics were stopped when specific clinical and laboratory criteria were met. Outcomes are compared to a historical group of patients treated under standard protocol (antibiotic prophylaxis followed by 48 hours of dual antibiotic therapy in simple appendicitis or 5 day-course of triple antibiotic therapy in complicated as postooperative antibiotic regimen). RESULTS: A total of 196 patients (96 current group and 100 historical group) were reviewed. In simple appendicitis average length of postoperative hospitalization was significantly lower in the current group (no statistical difference). 52.9% of complicated appendicitis in the current group were discharged home before 5th day without increasing the complication rate. When a wound infection or intraabdominal abscess occurs thrombocytosis (52%) and prolonged vomiting are the most frequent symptoms. CONCLUSION: No further postoperative treatment is needed in simple appendicitis. In complicated appendictis a short course of antibiotics according to clinical and laboratory criteria allows early discharge without major morbidity. Prolonged postoperative vomiting and thrombocytosis suggest infectious complications.

OBJETIVOS: Existen múltiples modalidades de tratamiento antibioterápico tras una apendicectomía en niños. Nuestro objetivo es desarrollar un nuevo protocolo para el tratamiento de las apendicitis que permita acortar la estancia hospitalaria sin aumentar las complicaciones. MATERIAL Y METODOS: Estudio prospectivo que analiza a los pacientes intervenidos de apendicitis tratados según el nuevo protocolo de antibioterapia durante un periodo de 7 meses. Dicho protocolo consiste en profilaxis quirúrgica en todos los casos y continuar con triple antibioterapia en las evolucionadas, con una duración variable según criterios clínico-analíticos establecidos previamente. Se comparan los resultados con los de un grupo histórico de pacientes tratados con el protocolo clásico (profilaxis y 48 horas de doble antibioterapia en las flemonosas y 5 días de triple en las evolucionadas). RESULTADOS: Se estudian un total de 196 pacientes (96 grupo actual y 100 grupo histórico). En las apendicitis flemonosas la estancia hospitalaria postquirúrgica media es significativamente menor en el grupo actual sin encontrar diferencias estadísticas en la tasa de complicaciones. El 52,9% de las apendicitis evolucionadas del grupo actual fueron dadas de alta antes del 5º día sin aumentar la tasa de complicaciones. De los pacientes que presentaron una complicación infecciosa el 52% asociaban trombocitosis y la clínica más frecuente fue de vómitos prolongados. CONCLUSIONES: No es necesario tratamiento antibioterápico postoperatorio en apendicitis simples. En las evolucionadas un tratamiento corto de antibióticos según criterios clínico-analíticos permite un alta precoz sin mayor morbilidad asociada. Los vómitos prolongados y la trombocitosis son indicadores de complicaciones infecciosas postoperatorias.

Can We Do Anything Else before Removing a Button Battery from the Esophagus?-Hyaluronic Acid.

OBJECTIVE: This article tests the protective effect of a commercially available mixture of hyaluronic acid, chondroitin sulfate, and poloxamer 407 on the damage caused by the exposure of esophageal mucosa to button batteries in an animal model. METHODS: Experimental study. Sixty porcine esophageal samples were distributed in three groups: control (CG), exposure (EG), and exposure-protection (EPG). In EG and EPG, one CR2032 button battery per sample was inserted, both were subdivided into 2-, 4-, 6-, and 24-hour exposure subgroups, with subsequent battery removal. EPG samples were irrigated with the solution 1 hour after battery exposure. Esophageal pH and final voltage of the battery were measured. RESULTS: pH in CG remained stable. No significant differences in pH at 1 hour were found between EG and EPG. In EPG, the pH of the mucosa exposed to the anode was lower than in GE at 2 hours (12.44 vs. 11.89, p = 0.203) and 4 hours (13.78 vs. 11.77, p < 0.0001). In the cathode pH was significantly higher in EG at 2 hours (2.5 vs. 4.11, p < 0.0001), 4 hours (2.33 vs. 4.78, p < 0.0001), and 6 hours (2.17 vs. 2.91, p < 0.0001). Significant voltage reduction at 1 hour was found in EG compared to EPG (0.48 vs. 1.08 V, p = 0.004). CONCLUSION: Exposure to hyaluronic acid solution buffers the acidification on the side exposed to the cathode and basification on the anode. This effect can be maintained up to 3 to 5 hours, even after stopping its application. Our results suggest that a solution containing hyaluronic acid could be used as an esophageal protector after accidental ingestion of button batteries.

["Fast-track" in pediatric urologic surgery: pronenephrectomy]. / Fast-track en urología infantil: nefrectomía en prono ambulatoria.

UNLABELLED: INTRODUCTION AND OBJETIVES: Minimal invasive surgery trends to get prompt recovery in terms of inmediate deambulation and early discharge from hospital, without increasing patient's discomfort neither postoperative complications. This "fast-track" protocol is being progresively introduced in a crescent number of urological procedures. We are evaluating the viability of applying it in retroperitoneoscopic prone- position nephrectomy. METHODS AND MATERIALS: We have performed a retrospective review of the clinical reports of the patients submitted to prone nephrectomy with hospitalization between 2007 and 2011 and we present patients submitted to this procedure in an outpatient basis (less than 8 hours hospital stay) from 2011. We have recorded epidemiological factors, diagnosis, surgical time, first postoperative week analgesic requirements, parents cofort and postoperative complications. RESULTS: All the procedures were performed retroperitoneoscopically in prone position using two trocars. We included 34 nephrectomies with a mean surgical time of 107 minutes. Mean postoperative stay was under 24 hours in 23 patients, two of them were discharged in the first 8 hours after the procedure. Hospital stay over this time was due to concomitant pre-existent pathology in 6 patients and to non urological fever in the remaining 3. Analgesia was excellent in every patient with endovenous non-steroid drugs, registering no pain after administering them orally. There were no complications. CONCLUSIONS: We believe that "fast-track" requirements can be applied to prone-retroperitoneoscopic nephrectomy in pediatric population, as long as they have no associated pathology. In our experience this surgical procedure can be included in day-case surgery, increasing patient's confort and with a positive economical impact.

A classification scheme for mixed-species bird flocks.

The literature on mixed-species flocks references a wide variety of bird associations. These studies, however, have used an array of unstructured characteristics to describe flocks, ranging from the temporal occurrence of flocking to the identity and behavioural features of constituent members, with little consensus on which key traits define and characterize a mixed-species flock. Moreover, although most studies report species-specific roles, there is no clear consensus about what these roles signify nor how to define them. This lack of consistency limits our ability to compare flocks from different habitats, regions and species pools. To unify this sizable body of literature, we reviewed and synthesized 538 studies on mixed-species flocks. We propose 13 categories to classify mixed-species flocks using behavioural and physical traits at the flock and participant level, as well as the habitat where the flock occurs. Lastly, we discuss the historical terminology for different species roles and propose definitions to clarify and distinguish among nuclear, leader, sentinel, and flock-following species. We envision that these guidelines will provide a universal language for mixed-species flock research, paving the way for future comparisons and new insight between different regions and systems. This article is part of the theme issue 'Mixed-species groups and aggregations: shaping ecological and behavioural patterns and processes'.

Impact of digestive-surgical cross-disciplinary management in patients with esophageal atresia. / Impacto del manejo multidisciplinar digestivo-quirúrgico en los pacientes con atresia de esófago.

OBJECTIVE: The objective of this study was to analyze whether patients undergoing esophageal atresia (EA) surgery benefit from a cross-disciplinary follow-up program, based on current clinical guidelines, implemented in our institution. MATERIALS AND METHODS: An observational, analytical, retrospective study of patients undergoing EA surgery from 2012 to 2022 was carried out. The results of a joint pediatric surgery and gastroenterology consultation program -which was implemented in 2018 and applies a protocol based on the new ESPGHAN-NASPGHAN guidelines- were analyzed. Patients were divided according to whether they had been treated before or after 2018. Quantitative variables -follow-up losses, anti-reflux treatment initiation and duration, and enteral nutrition initiation- and qualitative variables -prevalence of gastroesophageal reflux, anti-reflux surgery, respiratory infections, anastomotic stenosis, re-fistulizations, dysphagia, impaction episodes, need for gastrostomy, and endoscopic results- were compared. RESULTS: 38 patients were included. 63.2% had gastroesophageal reflux. 97.4% received anti-reflux treatment in the first year of life, with treatment being subsequently discontinued in 47.4%. Discontinuation time decreased by a mean of 24 months following program implementation (p< 0.05). A 4.6-fold increase in the frequency of pH-metries was noted following program implementation. The protocol standardized endoscopies in asymptomatic patients when they turn 5 and 10 years old. 25 endoscopies with biopsy were carried out after 2018, with histological disorders being detected in 28% of them. The number of follow-up losses significantly decreased following protocol implementation (p< 0.05). CONCLUSIONS: Digestive-surgical cross-disciplinary follow-up of EA patients has a positive impact on patient progression. Applying the guidelines helps optimize treatment and early diagnosis of complications.

OBJETIVOS: El objetivo de este estudio es analizar si los pacientes intervenidos de atresia de esófago (AE) se benefician de un programa de seguimiento multidisciplinar, basado en las guías clínicas actuales, implantado en nuestro centro. MATERIAL Y METODOS: Estudio retrospectivo, observacional y analítico incluyendo los pacientes intervenidos de AE entre 2012 y 2022. Se analizaron los resultados de la implantación en 2018 de un programa de consultas conjuntas de gastroenterología y cirugía pediátrica aplicando un protocolo basado en las nuevas guías ESPGHAN-NASPGHAN. Se dividieron a los pacientes tratados antes y después de 2018 y se compararon las variables cuantitativas: pérdidas de seguimiento, inicio y duración del tratamiento antirreflujo e inicio de nutrición enteral, y cualitativas: prevalencia de reflujo gastroesfoágico, realización de cirugía antirreflujo, infecciones respiratorias, estenosis de la anastomosis, refistulizaciones, disfagia, episodios de impactación, necesidad de gastrostomía y resultados de las endoscopias. RESULTADOS: Se incluyeron 38 pacientes. Un 63,2% presentaron reflujo gastroesofágico. El 97,4% tomaron tratamiento antirreflujo el primer año de vida que posteriormente se retiró en el 47,4%. El tiempo de retirada se redujo una media de 24 meses tras la aplicación del programa (p< 0,05). Se realizaron 4,6 veces más pHmetrías tras la implantación del programa. El protocolo estandarizó la realización de endoscopias en pacientes asintomáticos al cumplir 5 y 10 años. Se realizaron 25 endoscopias con tomas de biopsia después de 2018, detectando alteraciones histológicas en un 28%. El número de pérdidas de seguimiento se redujo de forma significativa tras la implantación del protocolo (p< 0,05). CONCLUSIONES: El seguimiento multidisciplinar digestivo-quirúrgico de los pacientes con AE genera un impacto positivo en su evolución. La aplicación de las guías facilita la optimización del tratamiento y el diagnóstico precoz de las complicaciones.

Network structure of avian mixed-species flocks decays with elevation and latitude across the Andes.

Birds in mixed-species flocks benefit from greater foraging efficiency and reduced predation, but also face costs related to competition and activity matching. Because this cost-benefit trade-off is context-dependent (e.g. abiotic conditions and habitat quality), the structure of flocks is expected to vary along elevational, latitudinal and disturbance gradients. Specifically, we predicted that the connectivity and cohesion of flocking networks would (i) decline towards tropical latitudes and lower elevations, where competition and activity matching costs are higher, and (ii) increase with lower forest cover and greater human disturbance. We analysed the structure of 84 flock networks across the Andes and assessed the effect of elevation, latitude, forest cover and human disturbance on network characteristics. We found that Andean flocks are overall open-membership systems (unstructured), though the extent of network structure varied across gradients. Elevation was the main predictor of structure, with more connected and less modular flocks upslope. As expected, flocks in areas with higher forest cover were less cohesive, with better defined flock subtypes. Flocks also varied across latitude and disturbance gradients as predicted, but effect sizes were small. Our findings indicate that the unstructured nature of Andean flocks might arise as a strategy to cope with harsh environmental conditions. This article is part of the theme issue 'Mixed-species groups and aggregations: shaping ecological and behavioural patterns and processes'.

[Postoperative anal prolapse in patients with anorectal malformations: 16 years of experience]. / Prolapso anal postoperatorio en pacientes con malformaciones anorrectales: 16 años de experiencia.

INTRODUCTION: Anal prolapse is a common postoperative complication related to anorectal malformations (MAR) surgery, which is sometimes considered to be insignificant and/or not worthy of further intervention. We analysed the causes of this complication and our current surgical protocols. MATERIAL AND METHODS: Since 1995, 26 patients with anal prolapse have been operated secondary to surgical correction of an anorectal pathology. The most common MAR in girls (12) was cloaca (10), and in boys (14) was anorectal atresia with prostate fistula (8). The symptoms were anal pain and bleeding associated with alterations in bowel control alterations. The diagnosis in most patients was made in the first months after surgery, during the period of anal dilatations period. The surgical procedure involves prolapse resection of the prolapse and a new anoplasty. In 18 patients (69%) the prolapse was corrected before the colostomy closure on an outpatient basis. The other 8 patients (31%) underwent prolapse surgery after colostomy closure, requiring hospitalisation. RESULTS: There were no immediate postoperative complications, improving continence and aesthetic anus appearance. In 4 patients the prolapse recurred, requiring further surgical correction. CONCLUSIONS: Anal prolapse is a possible minor complication after anorectal correction. MAR type, the quality of the perineal musculature and defects in surgical technique are the main factors determining ia prolapse will appearance. The anal prolapse surgery indication has been recently increased (including small unilateral prolapses) as long as they are done before the colostomy closure, due to good aesthetic and functional results, requiring only outpatient surgery.

[Surgical wound infections in newborns: analysis of risk factors]. / Infección de la herida quirúrgica neonatal: análisis de factores de riesgo.

UNLABELLED: The incidence of surgical wound infections in neonates is high and it has an associated morbidity which extends hospital stay and gets a worse prognosis. The purpose of this study is to analyze the risk factors associated with the development of surgical wound infection and to identify susceptible patients with modifiable factors. MATERIAL AND METHODS: Case-control study of 90 surgical procedures underwent in newborns. We analyze pre-, intra- and postoperative risk factors. MAIN RESULTS: There are statically significant differences in terms of wound infection in dirty and contaminated surgery, reoperation, lavage of abdominal cavity, preoperative hospital stay longer than 8 days and wound closure with reabsorbable material. Furthermore, the surgical site infection is more likely in preterms patients, with a previous positive culture infection and the use of invasive devices as mechanical ventilation or central venous access. We found no relationship between wound infection and surgical time, bleeding during surgery and preoperative skin preparation with antiseptics. CONCLUSIONS: Reoperative patients, in which dirty and contaminated surgery is performed, absorbable material for skin is used and who have a preoperative hospital stay longer than 8 days, are in risk of developping wound infection and they will require an aggressive antibiotic treatment and special postsurgical care.

[Subcutaneously inserted central intravascular devices in the pediatric oncology patient: can we minimize their infection]. / Dispositivos intravasculares centrales de inserción subcutánea en el paciente oncológico pediátrico, ¿podemos minimizar su infección?

Long-term indwelling central venous access devices are frequently used in pediatric patients. Their main complication is infection, that can even mean their removal. We try to identify the risk factors really involved in this complication and in their removal. We have made a retrospective review of 120 oncologic pediatric patients who received a central venous device between 2003 and 2009. We searched for epidemiologic, clinic, microbiologic and surgical risk factors. We made a comparative data analysis among: GROUP A, children who suffered device infection, GROUP B the others. Group A was divided into early infection (first month after implantation)/late infection, removed/not removed. Data were analized with statistical program SPSS. 29 suffered from leukemia, 19 from lymphoma and the main part, 72, from solid tumour. 31% experienced infection (GROUP A), being early in the 36% of them. 16% had to be withdrawn. Data analysis revealed statistical association with the age (p=0.015) and with the reception of chemiotherapic treatment the week before the surgical insertion. The rest of the studied factors did not revealed a real association, but could be guess a relationship among infection and leukemia, subclavian catheters, those patients whose deviced was introduced using a guide over a previous catheter and also transplanted. Related to early infection the only associateon founded was with the subclavian access (p=0.018). In conclusion, in our serie long-term central venous access infection was more frequent in the younger patients and also in those who had received chemotherapy the week before the catheter implantation. The tendency towards infection in leukemia, transplanted and subclavian carriers has to be studied in a prospective way with a larger number of oncologic children.

[Phimosis: dorsal slit or circumcision?]. / Fimosis: prepucioplastia o circuncisión?

INTRODUCTION: Phimosis is perhaps one of the most frequent consultation on pediatric surgery clinics throught the world. The aim of this study is to compare the two procedures more frequently performed in our hospital: dorsal slit and circumcision. PATIENTS Y METHODS: Retrospective study of 1698 patients who were admitted for elective surgical treatment of phimosis between 2003 and 2009. We analyzed age, surgical and anesthethic times, surgical technique and complications. We also did transversal descriptive study through telephonic survey on parents and patients older than 16 years old. RESULTS: There was 76.6% of dorsal slit (n = 1300) and 23.4% (n= 398) of circumcisions. Mean age was 7.15 years y mean time of follow up was 42.3 months. Surgical time was significantly higher in circumcision (p < 0.0001). There were 3% (n = 51) of reoperations, no differences between groups. We didn't find differences in postoperative stenosis, but bleeding was more frequent in circumcision group (1.7%; p = 0.03). There were no differences on parental appreciation of postoperative pain, or functional and esthetic satisfaction between groups. CONCLUSIONS: We didn't find differences on subjective satisfaction between groups. Even if there are differences n postoperative bleeding, global incidence is very low. In our experience both techniques are valid and safe, so surgeon and parents must jointly make the decision.

Thyroid surgery in pediatric patients: causes and results. / Cirugía tiroidea en la edad pediátrica: causas y resultados.

OBJECTIVE: Even though thyroid surgery is rare in pediatric patients, frequency has increased in the last years. The objective of this study was to analyze the causes and results of these procedures in a pediatric surgical facility. PATIENTS AND METHODS: Retrospective study including all patients requiring thyroid surgery in our department from 2000 to 2019. Demographic data, diagnostic data, associated pathology, type of surgical procedure, pathological results, and intraoperative and postoperative complications were recorded. RESULTS: 47 patients with a mean age of 8.9 ± 3.9 years at surgery were included. The most frequent diagnosis was MEN syndrome (n = 30, 29 MEN 2A and 1 MEN 2B), followed by thyroid papillary carcinoma (n = 5), follicular adenoma (n = 5), multinodular goiter (n = 4), follicular carcinoma (n = 1), thyroglossal duct papillary carcinoma (n = 1), and Graves-Basedow syndrome (n = 1). 38 total thyroidectomies (73.7% of which were prophylactic), 3 double hemithyroidectomies, 5 hemithyroidectomies, and 5 lymphadenectomies were performed. No intraoperative complications or recurrent laryngeal nerve lesions were noted. Mean postoperative hospital stay was 1.3 ± 0.6 days. 7 patients had transitory asymptomatic hypoparathyroidism, and 1 patient had persistent symptomatic hypoparathyroidism. Pathological results of prophylactic thyroidectomies were: 18 C cell hyperplasias, 7 microcarcinomas, and 3 cases without histopathological disorders. CONCLUSIONS: Thyroid surgery in pediatric patients is safe if performed by specialized personnel. Even though it remains rare, frequency has increased in the last years.

OBJETIVO: La cirugía tiroidea es poco frecuente en la edad pediátrica, aunque ha aumentado su frecuencia en los últimos años. El objetivo de este estudio es analizar las causas y los resultados de estos procedimientos en un centro quirúrgico pediátrico. METODOS: Estudio retrospectivo que incluyó a todos los pacientes que necesitaron cirugía tiroidea en nuestro servicio entre 2000-2019. Se recogieron datos demográficos, diagnóstico, patología asociada, tipo de procedimiento quirúrgico realizado, resultados anatomopatológicos y complicaciones intra y posoperatorias. RESULTADOS: Se incluyeron 47 pacientes con una edad media en el momento de la intervención de 8,9 ± 3,9 años. El diagnóstico más frecuente fue síndrome MEN2 (n = 30, 29 MEN2A y 1 MEN2B), seguido de carcinoma papilar de tiroides (n = 5), adenoma folicular (n = 5), bocio multinodular (n = 4), carcinoma folicular (n = 1), carcinoma papilar del conducto tirogloso (n = 1) y síndrome de Graves-Basedow (n = 1). Se realizaron 38 tiroidectomías totales (el 73,7% fueron profilácticas), tres dobles hemitiroidectomías, cinco hemitiroidectomías y en cinco casos fue necesario realizar una linfadenectomía. No se presentaron complicaciones intraoperatorias ni lesiones de nervio laríngeo recurrente. La estancia media posoperatoria fue de 1,3 ± 0,6 días. Siete pacientes presentaron hipoparatiroidismo transitorio asintomático y en un caso, persistente sintomático. Los resultados anatomopatológicos de las tiroidectomías profilácticas fueron: 18 hiperplasias de células C, 7 microcarcinomas y 3 sin alteraciones histopatológicas. CONCLUSIONES: La cirugía tiroidea en la edad pediátrica es segura en manos de equipos especializados. Aunque sigue siendo un procedimiento poco habitual, su frecuencia está aumentando en los últimos años.

Pediatric surgical activity during the SARS-CoV-2 pandemic: experience at a tertiary hospital. / Cirugía pediátrica durante la pandemia de SARS-CoV-2. Experiencia en un hospital de tercer nivel.

OBJECTIVES: The primary objective was to describe the characteristics and demographics of the surgical procedures carried out at a tertiary hospital during the SARS-CoV-2 pandemic. The secondary objective was to study the impact of the pandemic on the acute appendicitis cases treated at our healthcare facility and to compare them with a pre- SARS-CoV-2 period. MATERIAL AND METHODS: A retrospective study of all patients undergoing surgery at the pediatric surgery department in the pandemic period, from the beginning of the state of emergency in Spain until the first restrictions were removed, was conducted. RESULTS: A total of 61 patients underwent surgery in 58 days vs. 406 patients in the same 2019 period (p < 0.00001). 59.01% of surgeries were urgent. 5.1% of patients had a positive SARS-CoV-2 diagnostic test. 30 different procedures were carried out, with appendectomy being the most frequent one (n = 13, 19.6% of patients). 61.5% of appendicitis cases were complicated vs. 42.4% in the non-COVID period (p = 0.17). Surgical approach was open in 46.1% of patients vs. 6.1% in the non-COVID period (p = 0.004). No statistically significant differences were found in terms of complication rate or hospital stay. CONCLUSIONS: During the SARS-CoV-2 pandemic, a significant decrease in the number of daily procedures was noted, with more than half being urgent. Appendicular pathologies were in a more advanced stage than usual, with a clear trend towards open surgery vs. laparoscopy.

OBJETIVOS: Describir las características y demografía de los procedimientos quirúrgicos realizados en un hospital de tercer nivel durante la pandemia del SARS-CoV-2. Como objetivo secundario se estudia el impacto de la pandemia en las apendicitis agudas tratadas en nuestro centro y su comparación con un periodo previo al SARS-CoV-2. MATERIAL Y METODOS: Estudio retrospectivo incluyendo a todos los pacientes intervenidos por parte del Servicio de Cirugía Pediátrica durante el periodo de pandemia. Abarca desde el primer día del estado de alarma hasta la desescalada de las restricciones. RESULTADOS: Se intervinieron un total de 61 pacientes en 58 días frente a 406 pacientes durante el mismo periodo de 2019 (p < 0,00001). El 59,01% de las intervenciones eran de carácter urgente. Un 5,1% de los pacientes tuvieron un test diagnóstico de SARS-CoV-2 positivo. Se realizaron 30 procedimientos distintos, siendo el más frecuente la apendicectomía (n = 13, 19,6% de los pacientes). El 61,5% de las apendicitis fueron complicadas frente a un 42,4% en periodo no COVID (p = 0,17). El abordaje quirúrgico fue abierto en un 46,1% de los pacientes frente al 6,1% no COVID (p = 0,004). No hubo diferencias estadísticamente significativas en la tasa de complicaciones o la estancia hospitalaria. CONCLUSIONES: Durante la pandemia por SARS-CoV-2 se ha producido una importante disminución del número de procedimientos diarios, pasando a ser más de la mitad de carácter urgente. La patología apendicular se ha presentado más evolucionada de lo habitual, habiendo una clara tendencia a la cirugía abierta frente a la laparoscopia.

Laparoscopic surgery of congenital paraesophageal hernia in newborns and infants. / Cirugía laparoscópica de la hernia paraesofágica congénita en neonatos y lactantes.

INTRODUCTION: Congenital paraesophageal hernia (CPH) is a rare pathology in pediatric patients. Clinical signs may occur as early as in newborns, which means it requires early surgical repair. CLINICAL CASES: This is a series of three patients under 1 year of age diagnosed with type IV CPH - with symptoms occurring since they were newborns - who underwent laparoscopic surgical repair. One patient had been diagnosed prenatally. Age at surgery was 6 days, 36 days, and 9 months, respectively. Weight at surgery was 3.60 kg, 3.79 kg, and 8.20 kg, respectively. The patients underwent laparoscopy, with removal of the hernia sac, closure of the diaphragmatic pillars, placement of a reinforcement absorbable mesh, and Nissen fundoplication. Mean operating time was 130 minutes. No intraoperative complications were recorded. One patient developed a sliding hernia, which was subsequently repaired without complications. Mean follow-up time was 24 months.

INTRODUCCION: Las hernias paraesofágicas congénitas (HPC) son una patología poco frecuente en la edad pediátrica. Pueden presentar clínica desde la época neonatal precisando una reparación quirúrgica temprana. CASOS CLINICOS: Presentamos 3 casos diagnosticados de HPC tipo IV en pacientes menores de 1 año, que presentaron síntomas desde la época neonatal, en los que se ha realizado reparación quirúrgica laparoscópica. Un paciente presentaba diagnóstico prenatal. La edad en el momento de la cirugía fue 6 días, 36 días y 9 meses. El peso en el momento de la cirugía fue de 3,60 kg, 3,79 kg y 8,20 kg. Los pacientes fueron intervenidos por laparoscopia realizando excisión del saco herniario, cierre de pilares diafragmáticos, colocación de malla reabsorbible de refuerzo y una funduplicatura Nissen. El tiempo medio de cirugía fue de 130 minutos. No hubo complicaciones intraoperatorias. Un paciente presentó una hernia de deslizamiento que se reparó posteriormente sin complicaciones. El tiempo medio de seguimiento es de 24 meses.

[Evaluation of the long-term results of surgical treatment of palmar hyperhidrosis]. / Valoración de los resultados a largo plazo del tratamiento quirúrgico de la hiperhidrosis palmar.

INTRODUCTION: Palmar hyperhidrosis (PH) is a relative frequent pathology which basically affects patients' life quality limiting social and laboral life. The treatment of choice is thoracoscopic sympathectomy, most frequently done during adulthood. The aim of our study was to evaluate the degree of satisfaction of the pediatric patients treated in our centre. MATERIAL AND METHODS: We retrospectively reviewed the clinical records of the patients controlled and treated in our centre during the last 4 years evaluating the symptoms before surgery, the level of the sympathectomy and postoperative complications. To evaluate the long-term results we developed a telephone questionnaire for all the patients centralized on the grade of satisfaction, the efficiency of the treatment, the compensatory sweating and the observed changes in life quality. The medium follow-up time was 26.5 months (rango 6 months to 4 years). RESULTS: In total 6 patients were reviewed (4 female, 2 male), medium age 12, 8 years (rango 8 to 18 years). Thoracoscopic sympathectomy was done at the level of T2 or T3 associating T4 in 1 case. We just observed 1 postoperative complication which consisted in a disestesia of the upper extremity and which disappeared spontaneously without sequels. Patients referred total relief of palmar sweating. Only 1 case reported residual sweating unilaterally in the tenar region, but in all of them sweating of feet still persisted (3 of low grade and 3 of moderate grade). In 50% of the cases we observed compensatory sweating localized at the back of moderate grade in 2 patients and at the upper legs of more severe grade in 1 of them. Only this last patient reported that the compensatory sweating affected his everyday life. We also observed that the patients where the sympathectomy had affected more than 1 ganglia (T2+T3; T3+T4; T2+T3+T4) referred a higher grade of compensatory sweating. All the cases reported an important improvement in life quality, in the social as in the formative manner. They were all very satisfied with the results of the surgery and none of them (neither the children nor the parents) regretted the intervention. The cosmetic result of the surgical scars was also satisfactory. CONCLUSIONS: The thoracoscopic sympathectomy is an efficient procedure for the treatment of palmar hyperhidrosis. Despite the compensatory sweating patients usually are very satisfied with the results. Since palmar hyperhidrosis is not a pathology which improves spontaneously and the surgical treatment has minimal complications we do not think that the surgery should be postponed in pediatric patients.

[Hypertrophic pyloric stenosis: comparison between transversal and supraumbilical incision]. / Estenosis hipertrófica de píloro: comparación entre la incisión transversa y la supraumbilical.

BACKGROUND/PURPOSE: The treatment of hypertrophic pyloric stenosis is the Fredet-Ramstedt pyloromyotomy. It is controversial what surgical approach to choose. We evaluate our outcome with the right upper quadrant (RUQ) and the supraumbilical (SU) approach. METHODS: Between 2003 and 2007, we performed 38 pyloromyotomies through a RUQ incision and 18 through a SU approach. We analyze patient demographics and pre and postoperative data. We group the complications in major (duodenal perforation, inadequate pyloromyotomy, and wound dehiscence) and minor (seroma, hematoma, wound infection and incisional hernia). A nonrandomized comparison was performed between the two groups. RESULTS: We find significant differences in morbidity: 22.2% of major complications ocurred in the SU group versus 2.6% in the RUQ group, and 44.4% of minor complications were encountered in the SU group versus 2.6% in the RUQ group (P < 0.005). CONCLUSIONS: In our study we found a significantly higher overall complication rate in the SU group (p < 0.005), possibly because of a more difficult delivery of the pylorus through the SU incision and because of a probably increased rate of wound infection associated with the supraumbilical approach in the pediatric population.

[Percutaneous gastrostomy: when should antireflux surgery be associated?]. / Gastrostomía percutánea: ¿cuándo asociar cirugía antirreflujo?

INTRODUCTION: Percutaneus gastrostomy placement is a procedure widely performed in children with failure to thrive or intolerance to oral feeding. At the moment of making the indication, the need of an antir-reflux surgery in the same procedure comes to question. The aim of this study was to analyse which preoperative factors are associated with a higher risk of a posterior fundoplication. MATERIAL AND METHODS: We realized a retrospective review of 67 patients divided in 2 groups (cases and controls) in which a percutaneus gastrostomy (PEG) had been made by our service in the period of 1997 to 2008. We compared these two groups: Group A (n=11) - patients with severe gastroesophageal reflux who required a Nissen procedure afterwards; Group B (n=56) - patients who kept without reflux after PEG. We analyzed the different preoperative factors that could have been in association to severe reflux after gastrostomy. RESULTS: Mean age at the moment of undergoing PEG was 15 months. Mean time of follow up was 3,5 years. Only neurological impairment and documented reflux pregastrostomy were associated with the need of an antirreflux surgery after PEG. CONCLUSIONS: Neurological impairment and documented pregastrosotmy GER could be an indication of concurrent antirreflux surgery at the time of gastrostomy.

Bronchoalveolar lavage usefulness in the pediatric population. / Rentabilidad del lavado broncoalveolar en la población pediátrica.

OBJECTIVE: To analyze bronchoalveolar lavage diagnostic effectiveness and impact on therapeutic management in pediatric patients. MATERIAL AND METHODS: Retrospective study of patients undergoing bronchoalveolar lavage at the pediatric surgery department from 2009 to 2019. The sample was divided into two groups: hemato-oncological patients and non-hemato-oncological patients. Demographic variables, bronchoalveolar lavage result, and subsequent therapeutic attitude were collected. RESULTS: 45 bronchoalveolar lavages were carried out in 38 patients. The hemato-oncological group consisted of 25 bronchoalveolar lavages. Patient mean age was 9.99 ± 2.34 years. 80% of patients had received anti-infective treatment prior to bronchoalveolar lavage. Bronchoalveolar lavage culture was positive in 52% of cases. Bronchoalveolar lavage results translated into therapeutic management change in 24% of cases (6/25). 3 postoperative complications were recorded, all mild. In the non-hemato-oncological group (n = 20), mean age was 6.70 ± 5.17 years. Bronchoalveolar lavage was positive in 25% of cases, and translated into management change in 5% of patients. Complication rate in this group was 30%. 2 patients required mechanical ventilation. CONCLUSIONS: According to our results, bronchoalveolar lavage in hemato-oncological patients helps achieve microbiological diagnosis in infectious respiratory conditions and is relatively well-tolerated. In non-hemato-oncological patients, diagnostic and therapeutic usefulness is low, and complication rate is not negligible. The risk-benefit balance should be individually considered in each patient.

OBJETIVO: Analizar la eficacia diagnóstica del lavado broncoalveolar y su impacto en el manejo terapéutico en pacientes pediátricos. MATERIAL Y METODOS: Estudio retrospectivo incluyendo a los pacientes a los que se les realizó un lavado broncoalveolar por parte del Servicio de Cirugía Pediátrica entre 2009 y 2019. Se ha dividido la muestra en dos grupos: pacientes hemato-oncológicos y no hemato-oncológicos. Se han recogido variables demográficas, el resultado del lavado broncoalveolar y la actitud terapéutica posterior. RESULTADOS: Se realizaron 45 lavados broncoalveolares en 38 pacientes. El grupo hemato-oncológico constaba de 25 lavados broncoalveolares. Los pacientes tenían una edad media de 9,99 ± 2,34 años. El 80% de los pacientes tenían tratamiento antiinfeccioso previo al lavado broncoalveolar. El cultivo del lavado broncoalveolar fue positivo en el 52% de los casos. El resultado del lavado broncoalveolar influyó en un cambio de manejo terapéutico en un 24% (6/25). Se produjeron 3 complicaciones postoperatorias, todas leves. En el grupo no hemato-oncológico (n = 20) la edad media era de 6,70 ± 5,17 años. El lavado broncoalveolar fue positivo en el 25% y supuso un cambio de manejo en un 5% de los pacientes. Este grupo tuvo una tasa de complicación del 30%, 2 pacientes requirieron ventilación mecánica. CONCLUSIONES: Según nuestros resultados, el lavado broncoalveolar en los pacientes hemato-oncológicos ayuda al diagnóstico microbiológico en procesos respiratorios infecciosos y es relativamente bien tolerado. En los no hemato-oncológicos, tiene una baja rentabilidad diagnóstico-terapéutica con una tasa de complicaciones no desdeñable. Sería necesario individualizar el balance beneficio-riesgo en cada paciente.

Measuring esophageal anastomotic stricture index as a predictor of dilatation following esophageal atresia surgical repair. / Medición del índice de estenosis de la anastomosis esofágica como predictor de dilatación tras la corrección quirúrgica de la atresia esofágica.

INTRODUCTION: Anastomotic stricture is the most common complication following esophageal atresia (EA) surgical repair. The objective of this study was to evaluate Anastomotic Stricture Index (ASI: relationship between pouch and stricture diameters in the postoperative esophagram) as a predictor of the need for esophageal dilatation. METHODS: A retrospective review of all patients undergoing EA repair in our healthcare facility from 2009 to 2017 was designed. Proximal pouch ASI (proximal ASI) and distal pouch ASI (distal ASI) in the first and second postoperative esophagram were calculated, and correlation with the number of esophageal dilatations required was studied. For statistical analysis purposes, Spearman's correlation test and ROC curves were used. RESULTS: Of the 31 patients included, 21 (67.7%) required esophageal dilatation, and 11 (35.5%) required 3 or more dilatations. The relationship between ASIs in the first esophagram and the need for esophageal dilatation was not statistically significant (p >0.05). The relationship between proximal ASI (RHO = 0.84, p <0.05) and the number of dilatations in the second esophagram was statistically significant. None of the patients with <0.55 proximal ASI required dilatation; patients with 0.55-0.79 proximal ASI required less than 3 dilatations; and patients with >0.79 proximal ASI had a high risk of requiring 3 or more dilatations. CONCLUSION: According to our study, measuring ASI in the second esophagram proves useful in predicting EA patients' postoperative management, especially when it comes to identifying patients with lower risk of undergoing multiple dilatations.

INTRODUCCION: La estenosis esofágica es la complicación más frecuente tras la corrección de la atresia esofágica (AE). El objetivo de este estudio es el análisis de los Índices de estenosis de la anastomosis (IEA: relación entre los diámetros de los bolsones y de la estenosis en el esofagograma postoperatorio) como predictores de la necesidad de dilatación esofágica. METODOS: Se diseña un estudio retrospectivo incluyendo los pacientes con AE y anastomosis esofágica en nuestro centro entre 2009-2017, calculando los IEA del bolsón proximal (IEA-proximal) y distal (IEA-distal) en el primer y segundo esofagograma postoperatorio, analizando su correlación con el número de dilataciones esofágicas que necesitaron. Para el análisis estadístico, se ha empleado el test de correlación de Spearman y las curvas ROC. RESULTADOS: Se incluyeron 31 pacientes: 21 precisaron dilatación esofágica (67%), y 11 de ellos (35%) 3 o más dilataciones. No se demostró relación estadísticamente significativa entre los IEA del primer esofagograma con la necesidad de dilatación esofágica (p >0,05). Se observó una relación entre el IEA-proximal (rho = 0,84, p <0,05) y el número de dilataciones en el segundo esofagograma. Ningún paciente con ASI-proximal <0,55 necesitó dilatación; los pacientes con ASI-proximal entre 0,55-0,79 precisaron menos de 3 dilataciones y los pacientes con ASI-proximal >0,79 presentaron alto riesgo de necesitar 3 o más dilataciones. CONCLUSION: Según los resultados de nuestro estudio, la medición de IEA en el segundo esofagograma constituye una herramienta útil para predecir el manejo postoperatorio en pacientes con AE, especialmente en la identificación de aquellos con menor riesgo de someterse a múltiples dilataciones.

Enhanced secretion of amylase from exocrine pancreas of connexin32-deficient mice.

To determine whether junctional communication between pancreatic acinar cells contributes to their secretory function in vivo, we have compared wild-type mice, which express the gap junctional proteins connexin32 (Cx32) and connexin26, to mice deficient for the Cx32 gene. Pancreatic acinar cells from Cx32 (-/-) mice failed to express Cx32 as evidenced by reverse transcription-PCR and immunolabeling and showed a marked reduction (4.8- and 25-fold, respectively) in the number and size of gap junctions. Dye transfer studies showed that the extent of intercellular communication was inhibited in Cx32 (-/-) acini. However, electrical coupling was detected by dual patch clamp recording in Cx32 (-/-) acinar cell pairs. Although wild-type and Cx32 (-/-) acini were similarly stimulated to release amylase by carbamylcholine, Cx32 (-/-) acini showed a twofold increase of their basal secretion. This effect was caused by an increase in the proportion of secreting acini, as detected with a reverse hemolytic plaque assay. Blood measurements further revealed that Cx32 (-/-) mice had elevated basal levels of circulating amylase. The results, which demonstrate an inverse relationship between the extent of acinar cell coupling and basal amylase secretion in vivo, support the view that the physiological recruitment of secretory acinar cells is regulated by gap junction mediated intercellular communication.